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Medicare Issues Amendment to QMB Rules

Medicare issues amendment to Qualified Medicare Beneficiary (QMB) rules.


On June 28th, 2017, Medicare issued an amendment to the Qualified Medicare Beneficiary (QMB) rules. It is against federal law to bill a Qualified Medicare Beneficiary (patient has Medicare and Medicaid). Civil monetary penalties can be assessed for billing a QMB. Medicare estimates that 1 out of 10 Medicare beneficiaries is a QMB. The problem has been that providers cannot easily recognize who is a QMB, and thus, are unknowingly billing them. The QMB indicators will initiate new messages on the Remittance Advice that reflect the beneficiary’s status and lack of liability for Medicare cost-sharing with three new Remittance Advice Remark Codes (RARC) that are specific to those enrolled as qualified medicare beneficiaries.

As appropriate, one or more of the following new codes will be returned:

  • N781 – No deductible may be collected as the patient is a Medicaid/Qualified Medicare Beneficiary.*
  • N782 – No coinsurance may be collected as the patient is a Medicaid/Qualified Medicare Beneficiary.*
  • N783 – No co-payment may be collected as the patient is a Medicaid/Qualified Medicare Beneficiary.*

*Review your records for any wrongfully collected coinsurance, deductible or co-payments.

Is provider action needed?

The CMS MLN Matters article reminds us that all Medicare suppliers and providers may not bill those enrolled in the QMB Program. Erroneous charges to those enrolled should be recalled and refunded. Stay up-to-date with any additional amendments made to the QMB Program by visiting the HIPAA Eligibility Transaction System.

Ways to promote compliance with QMB rules:

The following tips can help ensure compliance with QMB rules. Share this information with all office staff or create an office bulletin which can be referenced at all times.

  • Create a process to accurately identify QMB enrollees.
  • Make sure billing procedures and third-party vendors exempt QMB individuals.
  • Confirm the billing process in the states which your practice operates.
QMB billing requirement reminders:

Keep in mind the following requirements when dealing with QMB participants. These requirements apply to all those under the QMB umbrella and should go hand-in-hand with the above compliance rules.

  • All providers and suppliers must abide by the billing prohibitions.
  • Those enrolled as a QMB retain protection from billing across state lines.
  • QMB enrollees cannot waive their status and choose to pay Medicare cost-sharing.

Understanding these rules and implementing reminders can drastically increase compliance to help avoid federal violations. Keep in mind that as of October 2nd, 2017, providers will be more likely subject to penalties if a QMB is billed.

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posted by OBarros
posted in Healthcare Management
posted date Oct 2017